Mohammed Fahad Ali, MD1, Gregory T. Brennan, MD1, Jason Samarasena, MD, FACG1, John Lee, MD2
1University of California Irvine Medical Center, Orange, CA; 2University of California Irvine, Orange, CA
Introduction: Ectopic varices are rare and by definition occur outside of the esophagus and stomach. They can be found in the rectum, duodenum or be peristomal. An estimated 2-5% of variceal bleeds are due to ectopic varices with the majority occurring either in the rectum or duodenum. The diagnosis of ectopic duodenal varices can be challenging given their location. There is a paucity of data regarding optimal diagnosis and management of bleeding duodenal varices.
Case Description/Methods: A 46 year old woman with a history of cirrhosis from alcohol and nonalcoholic steatohepatitis was referred to our center for ongoing small bowel bleeding. Previous endoscopic evaluation included an unremarkable EGD, colonoscopy revealed blood through the colon without lesions, and capsule endoscopy showed blood in the proximal small bowel (at less than 30% small bowel transit time). We performed a push enteroscopy which showed a submucosal bulge with overlying ulceration and intermittent active bleeding in the third portion of the duodenum. Hemostasis was achieved with two hemoclips and the location was marked with tattoos. On initial discovery, the lesion was most consistent with a submucosal tumor such as a GIST (figure 1) and she was referred for surgical resection. However, surgery was unsuccessful because of dense adhesions from a prior unrelated surgery. A repeat examination of the lesion 6 weeks later with endoscopic ultrasound showed a large varix (figures 2 and 3). The patient has otherwise been doing well without any recurrent GI bleeding.
Discussion: Varices typically appear as bluish enlarged vessels or bulges and are commonly tortuous and easily compressed with instrumental pressure. Ectopic varices can be confused with thickened folds or submucosal lesions as in this case. Differentiation of these lesions is paramount in choosing appropriate management. It is important to consider ectopic varices on the differentials of both GI hemorrhage and submucosal lesions. EUS is the preferred test to characterize such lesions. Varices typically appears as round anechoic structures arising from the lamina propria or submucosa. Color Doppler is used to detect blood flow, which will confirm the vascular nature of the structure. Options of endoscopic hemostasis of bleeding duodenal varices include hemoclips, sclerotherapy, TIPS, balloon-occluded retrograde transvenous obliteration or surgical resection.
Citation: Mohammed Fahad Ali, MD; Gregory T. Brennan, MD; Jason Samarasena, MD, FACG; John Lee, MD. P1340 - A RARE CAUSE OF SMALL BOWEL BLEEDING FROM A DUODENAL VARIX. Program No. P1340. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.